Tobacco- and Nicotine-Containing Product Use in Italy: Results From Two Cross-Sectional Studies

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BACKGROUND: Heated tobacco products (HTPs) are alternatives to cigarettes that heat rather than burn tobacco. The first HTP sold in Italy was _IQOS®_ (I-HTP), and while it has been available for nearly a decade, limited data are available on the use of these products. OBJECTIVE: To characterize how Italian adults (users of legal age) use tobacco- and nicotine-containing products (TNPs), including smoke-free products (SFPs), we surveyed this population about their current and past use of TNPs from 2018 to 2020. METHODS: Two consecutive cross-sectional surveys were conducted in representative samples of the general adult population (6,095 subjects from 2018 to 2019 and 6,118 from 2019 to 2020) and among adult I-HTP users (1,371 subjects from 2018 to 2019 and 1,401 from 2019 to 2020) in Italy. We assessed the prevalence of current TNP use in the general population sample and use patterns in the I-HTP_ _users sample. RESULTS: In the first cross-sectional study (2018-2019), cigarettes were the most used TNP (24.3%), while only a small proportion of the surveyed general population sample used e-cigarettes or I-HTPs (1.4% and 0.7%, respectively). Nearly all current I-HTP users were current adult cigarette smokers when they started using I-HTPs (98.0%). Both surveys showed low initiation, re-initiation, and relapse with I-HTPs, with the majority of current I-HTP users belonging to the intended audience of adults who already used TNPs. Some participants used both I-HTPs and combustible TNPs (38.6%); however, most (59.2%) used I-HTPs exclusively. I-HTP_ _users perceived the health risk (score 0 = no risk; score 100 = very high risk) associated with cigarette smoking higher (63.7) than that for I-HTP_ _use (42.6). Exclusive I-HTP users reported improved respiratory symptoms (reduced cough and phlegm) and exercise capacity compared to a year before they started using I-HTPs. Most current I-HTP users also reported improved smell and taste, better breath smell, and reduced stains or yellowing teeth. Overall, these results were more pronounced among exclusive I-HTP users. The results of the second cross-sectional study (2019-2020) were similar, except for an increase in I-HTP_ _use_ _(1.1% vs. 0.7% in 2018 to 2019). CONCLUSIONS: These studies show that most TNP users in Italy smoke cigarettes. The uptake of I-HTPs suggests that they are a viable alternative to cigarettes. Nearly all I-HTP users switched from cigarettes to I-HTPs. Furthermore, most I-HTP_ _users exclusively use the product. I-HTP users considered the health risk associated with I-HTP_ _use to be lower compared to cigarette smoking, but they did not perceive I-HTPs_ _as risk free. Study participants reported improvements on some health, hygiene, and appearance aspects after switching from cigarettes to I-HTPs. Our results suggest that SFPs can play a role in a harm reduction approach. Further studies are needed to continually monitor the prevalence of SFP use to provide long-term evidence of their impact.